Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal,newborn and child health

Introduction

Preconception care includes any intervention to optimize a woman’s health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

Methods

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

Results

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

Conclusion

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.

     

Evaluation of Severe Maternal Outcomes to Assess Quality of Maternal Health Care at a Tertiary Center

Background

Maternal mortality and near-miss index reflect the quality of care provided by a health facility. The World Health Organization recently published near-miss approach where strict near- miss criteria based on markers of organ dysfunction are defined.

Objectives

The aim of the study was to determine the frequency of severe maternal complications, maternal near-miss cases and maternal deaths, to analyze causes of near-miss and maternal mortality and to determine the values of maternal near-miss indicators.

Methods

This was a prospective observational study conducted at a tertiary care centre in North India from January 2012 – March 2013. WHO's near-miss approach was implemented for evaluation of severe maternal outcomes and to assess the quality of maternal health care.

Results

The number of women attending our facility with severe maternal complications was low (205 in 6,767 live births); as a result maternal near-miss ratio (MNMR) was low; 3.98/1,000 live births; Overall Maternal near-miss mortality ratio (MNM:1MD) was also low, 3.37:1, because of strict criterion of labeling near-miss and delay in referral to the hospital. Hypertensive disorder (37.5 %) was the commonest underlying cause for maternal mortality.

Conclusion

Basic implementation of WHO near-miss approach helped in the systematic identification and evidence-based management of severe maternal complications thereby improving the quality of maternal health in a developing country.

     

Comparison of maternal and fetal complications in elective and emergency cesarean section: a systematic review and meta-analysis

Background

Though the same types of complication were found in both elective cesarean section (ElCS) and emergence cesarean section (EmCS), the aim of this study is to compare the rates of maternal and fetal morbidity and mortality between ElCS and EmCS.

Methods

Full-text articles involved in the maternal and fetal complications and outcomes of ElCS and EmCS were searched in multiple database. Review Manager 5.0 was adopted for meta-analysis, sensitivity analysis, and bias analysis. Funnel plots and Egger’s tests were also applied with STATA 10.0 software to assess possible publication bias.

Results

Totally nine articles were included in this study. Among these articles, seven, three, and four studies were involved in the maternal complication, fetal complication, and fetal outcomes, respectively. The combined analyses showed that both rates of maternal complication and fetal complication in EmCS were higher than those in ElCS. The rates of infection, fever, UTI (urinary tract infection), wound dehiscence, DIC (disseminated intravascular coagulation), and reoperation of postpartum women with EmCS were much higher than those with ElCS. Larger infant mortality rate of EmCS was also observed.

Conclusion

Emergency cesarean sections showed significantly more maternal and fetal complications and mortality than elective cesarean sections in this study. Certain plans should be worked out by obstetric practitioners to avoid the post-operative complications.

     

Over-the-counter MTP Pills and Its Impact on Women’s Health

Objectives

To study the complications and consequences including maternal morbidity and mortality following indiscriminate self-consumption of abortion pills reporting to a tertiary care center.

Methodology

This is an observational study conducted at Vanivilas hospital between January 2012 to December 2013 for 24 months. After applying inclusion and exclusion criteria, 104 women were studied with respect to period of gestation, parity, clinical features at presentation and management in the institution. An analysis of maternal morbidity and mortality was done with respect to surgical interventions, ICU admissions, need for blood transfusions and maternal deaths.

Observations and results

In this study, there were 75 (72.2 %) cases of incomplete abortion, 10 (9.6 %) cases of missed abortion, 2 (1.9 %) cases of ruptured ectopic and 2 (1.9 %) cases of rupture uterus. Seventy-eight (75 %) cases received blood transfusion, 7 (6.7 %) were admitted to ICU, and 2 (1.9 %) developed acute kidney injury. There were 2 (1.9 %) maternal deaths in the study group.

Conclusion

This study shows urgent need for legislation and restriction of drugs used for medical termination of pregnancy. Drugs should be made available via health care facilities under supervision to reduce maternal mortality and morbidity due to indiscriminate use of these pills.

     

A Study of Hepatitis E in Pregnancy: Maternal and Fetal Outcome

Purpose

HEV infection, a major public health concern, is known to cause large-scale epidemic and sporadic cases of acute viral hepatitis in developing countries. The infection occurs primarily in young adults and is generally mild and self-limiting; however, the case fatality rate is reportedly higher among women, especially during the second or third trimesters of pregnancy.

Methods

This study, a prospective observational study, was conducted at the Dr. D. Y. Patil Medical College Hospital and Apple Saraswati Multispeciality hospital, in Kolhapur for over a period of 3 years (Jan 2010 to Jan 2013) to find out the prevalence and clinical outcome in a series of HEV-infected pregnant women.

Results

A total of fifty-five symptomatic Anti-HEV IgM-positive women were included, and the maternal-fetal outcome was analyzed. The maternal mortality was 5 % including one antenatal death. Prematurity (80 %) and PROM (11 %) were the commonest fetal complications noted with a vertical transmission rate of 28 %.

Conclusion

Variations in maternal morbidity and mortality between different studies indicate a need to subtype the viral genotype according to its virulence and morbidity.

     

The role of human rights litigation in improving access to reproductive health care and achieving reductions in maternal mortality

Background

Improving maternal health, reducing global maternal mortality, and working toward universal access to reproductive health care are global priorities for United Nations agencies, national governments, and civil society organizations. Human rights lawyers have joined this global movement, using international law and domestic constitutions to hold nations accountable for preventable maternal death and for failing to provide access to reproductive health care services.

Case presentation

This article discusses three decisions in which international treaty bodies find the nations of Brazil and Peru responsible for violations of the Convention on the Elimination of All Forms of Discrimination Against Women and the International Covenant on Civil and Political Rights and also two domestic decisions alleging constitutional violations in India and Uganda.

Conclusions

The authors analyze the impact of these decisions on access to maternal and other reproductive health services in Brazil, Peru, India, and Uganda and conclude that litigation is most effective when aligned with ongoing efforts by the public health community and civil society organizations. In filing these complaints and cases on behalf of individual women and their families, legal advocates highlight health system failures and challenge the historical structures and hierarchies that discriminate against and devalue women. These international and domestic decisions empower women and their communities and inspire nations and other stakeholders to commit to broader social, economic, and political change. Human rights litigation brings attention to existing public health campaigns and supports the development of local and global movements and coalitions to improve women’s health.

     

Maternal sepsis in the era of genomic medicine

Purpose

Maternal sepsis remains one of the leading causes of direct and indirect maternal mortality both in high- and low-income environments. In the last two decades, systems biology approaches, based on ‘-omics’ technologies, have started revolutionizing the diagnosis and management of the septic syndrome. The scope of this narrative review is to present an overview of the basic ‘-omics’ technologies, exemplified by cases relevant to maternal sepsis.

Methods

Narrative review of the new ‘-omics’ technologies based on a detailed review of the literature.

Results

After presenting the main ‘omics’ technologies, we discuss their limitations and the need for integrated approaches that encompass research efforts across multiple ‘-omics’ layers in the ‘-omics’ cascade between the genome and the phenome.

Conclusions

Systems biology approaches are revolutionizing the research landscape in maternal sepsis. There is a need for increased awareness, from the side of health practitioners, as a requirement for the effective implementation of the new technologies in the research and clinical practice in maternal sepsis.

     

Patients with high-risk pregnancies and complicated deliveries have an increased risk of maternal postpartum readmissions

Objective

Postpartum readmission after initial hospitalization for delivery can be diminished if better understood. The aim of this study was to determine the risk factors and indications for maternal re-hospitalization after delivery, in order to identify preventable factors.

Study design

This was a case control study based on retrospective cohort of patients who delivered at our institution. The patients that were readmitted within 2 weeks of their delivery were included in the study group while the control group was conducted from patients who delivered at the same time but were not re-hospitalized and included twice the number of patients. Demographic characteristics as well as pregnancy, labour and postpartum courses were compared between the two groups.

Results

A total of 227 women were re-hospitalized within 14 days after initial discharge. The control group consisted of 450 women. The demographic characteristics were similar among the two groups, so were the rates of obesity, gestational weight gain and smoking. The major indication for readmission was postpartum infections, most of which were not related to immediate postpartum febrile morbidity. Emergency cesarean section was found to be an independent risk factor for readmission.

Conclusions

The rate of patients with high-risk pregnancies and complicated deliveries is higher among postpartum maternal readmissions. These data might suggest more cautious postpartum care for those patients.

     

An effect of maternal nifedipine therapy on fetoplacental blood flow: a prospective study

Purpose

The aim of this study is to assess the effects of maternal nifedipine administration on placental and fetal blood flow.

Methods

A total of 29 patients with preterm labor diagnosis admitted to the tertiary care center, Zeynep Kamil Hospital, were evaluated. Before and 24–48 h after administration of oral nifedipine, Doppler ultrasound scan was carried out to measure fetal middle cerebral artery, ductus venosus, umbilical artery, and maternal uterine artery blood flow.

Results

After 24 and 48 h of therapy, there were no changes in mean PI and RI in the umbilical arteries and ductus venosus (p?>?0.05). Fetal middle cerebral artery and maternal uterine artery PI and RI values showed a significant reduction 24–48 h after oral nifedipine therapy (p?<?0.05).

Conclusions

Our study showed that 24 and 48 h after oral nifedipine therapy, there is a significant increase in fetal MCA and maternal uterine artery blood flow, while fetal umbilical artery and ductus venosus Doppler values do not change.

     

First-Trimester Uterine Artery Pulsatility Index and Maternal Serum PAPP-A and PlGF in Prediction of Preeclampsia in Primigravida

Background

Preeclampsia is a heterogeneous disorder affecting different body systems and frequently associated with morbidity and mortality. Early preeclampsia prediction will reduce this associated morbidity and mortality as it will give the chance for frequent maternal and fetal surveillance and application of prophylactic procedures.

Objective

The aim of this work is to evaluate the role of mean pulsatility index (PI) of the uterine arteries and maternal serum concentrations of pregnancy-associated plasma protein A (PAPP-A) and placental growth factor (PlGF) in early preeclampsia prediction in primigravida.

Patients and Methods

Three hundred primigravida attending the antenatal care clinic in Zagazig University Hospitals were included in the study. The mean PI of the uterine arteries was calculated. Maternal serum levels of PAPP-A and PIGF were analyzed by specific immunoassay.

Results

Three hundred women were included in the final analysis, of them 30 patients (10%) suffered from preeclampsia. There was a significant difference between preeclamptic and normal women as regards the mean PI of the uterine arteries and levels of PAPP-A and PIGF at 11–13 weeks. When combining the cutoff levels of the three methods, mean PI of the uterine arteries ≥1.69, PAPP-A assay <0.96 multiple of median (MoM) and PlGF assay <0.91 MoM, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy were 56.7, 99.3, 89.5, 95.4 and 67%, respectively.

Conclusion

The combined measurement of maternal serum PAPP-A and PlGF concentrations and mean PI of the uterine arteries at 11–13 weeks of pregnancy may help to predict preeclampsia in primigravida when other parameters of preeclampsia prediction are normal. However, we need more studies on larger and variable populations to evaluate the use of those combined methods in preeclampsia prediction.

     

A dose–response relation exists between different classes of pre-gravid obesity and selected perinatal outcomes

Objective

To examine if a “dose–response” relation exists between different classes of pre-gravid obesity and selected perinatal outcomes.

Methods

We evaluated 16,566 obese mothers, including 12,064 (72.8%), 3410 (20.6%), and 1092 (6.6%) with obesity class I, II, and III, respectively. We compared maternal age, primiparity, gestational age at birth, birth weight, GDM, hypertensive disorders, and the incidence of cesarean sections.

Results

There was a significantly increased incidence (from class I to class III) for GDM (8.5–14.4%), chronic hypertension (2.8–9.0%), gestational hypertension (6.7–14.2%), and for preeclampsia (5.3–9.3%). No such relationship existed for birth weight and gestational duration.

Conclusion

Classes of obesity during pregnancy exhibit a “dose–response” relationship with maternal morbidity, but no such relationship was found with pregnancy duration and birth weight.

     

An overview of maternal and fetal short and long-term impact of physical activity during pregnancy

Purpose

To explore information available in the literature about the possible benefits resulting from physical activity (PA) in non-risky pregnant women, repercussion on maternal organism, fetal development, and on long-term offspring health.

Methods

Critical narrative review using online databases.

Results

Through critical discussion of studies focused on PA practiced during pregnancy, it was observed that some of the outcomes investigated on both mother and offspring showed conflicting findings. Considering the impact of maternal PA in certain offspring characteristics, due to the fact that their findings come from studies with small samples, they do not allow the stablishment of scientific evidence. However, a feature that shows broad consensus among studies is the view of PA during pregnancy as a safe intervention for mother and fetus. In situations where studies employing PA of moderate-intensity have not enough power to ensure a positive influence on certain clinical outcomes, what is observed is the lack of their influence, not negative impacts. Regarding epigenetic modulations measured late in the offspring, it has been attributed to PA a positive modulatory role on metabolic, hemodynamic and even on behavioral characteristics. However, possible mechanisms involved in these epigenetic changes have not been sufficiently explored.

Conclusion

Maternal PA appears to be safe for both mother and fetus, and additional studies are needed to confirm the real influence of this practice in the offspring, as well as the perpetuation and transfer of these features between generations.

     

In Pursuit of Solving a Global Health Problem: Prototype Medical Device for Autotransfusing Life-Threatening Postpartum Hemorrhage in Resource-Limited Settings

Purpose of Review

The purpose of the review is to provide an overview of innovative technologies being developed to prevent and treat postpartum hemorrhage in resource-limited settings and to discuss a promising new device designed specifically to address the lack of safe blood supplies in many areas of the world.

Recent Findings

There are several new technologies being used or tested to address the significant global health problem of postpartum hemorrhage, the leading cause of maternal morbidity and mortality worldwide. None of these new technologies have addressed the persistent lack of safe blood supplies in low resource settings which is an essential pillar of comprehensive emergency obstetric care. With this aim in mind, a prototype obstetrical medical device was designed with the capability to autotransfuse women suffering life-threatening postpartum hemorrhage in low resource settings.

Summary

Postpartum hemorrhage remains the leading cause of maternal morbidity worldwide and efforts are needed, more than ever, to achieve the Sustainable Development Goals of improving maternal mortality especially in resource-limited settings. Despite many effective new technologies such as the non-pneumatic anti-shock garment, improvised uterine balloon tamponade devices, and new drugs such as tranexamic acid, none has addressed the lack of safe blood supplies that are critical to treating PPH. A prototype medical device has been developed, and preliminary testing for functionality and filter function has been successful and shows great promise. Further testing is still needed and is ongoing in preparation for human clinical trials.

     

Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section

Purpose of investigation

We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity.

Materials and methods

We analyzed intra-abdominal adhesions of 672 patients.

Results

Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively.

Conclusions

Emergency operations and adhesions increased complications.

     

Unscarred Uterine Rupture: A Retrospective Analysis

Introduction

Uterine rupture is a catastrophic obstetrical emergency associated with a significant feto-maternal morbidity and mortality. Many risk factors for uterine rupture, as well as a wide range of clinical presentations, have been identified.

Objectives

To analyze the frequency, predisposing factors, and maternal and fetal outcomes of uterine rupture.

Methods

A retrospective analysis of cases of unscarred uterine rupture was conducted at the Department of Obstetrics and Gynecology, RIMS, Imphal from June 1, 2010 to June 30, 2012.

Results

Our analysis comprised 13 cases. Of these, 30.8 % were booked cases. Most of the cases (46.2 %) were Para 2. Uterine rupture occurred at term in 10 cases. The rupture occurred due to mismanaged labor (30.8 %), the use of oxytocin (23 %), instrumental delivery (15.4 %), obstructed labor (15.4 %), induction by prostaglandin gel (7.7 %), and placenta percreta (7.7 %). Maternal deaths and perinatal deaths were 30.8 and 53.8 %, respectively. Sub-total hysterectomy was done in 8 cases and in 1 patient laparotomy with repair was performed.

Conclusion

Ruptured uterus causes a high risk in patients. An unscarred uterus can undergo rupture even without etiological or risk factors. The patients with mismanaged labor, grand multiparas, and obstructed prolonged labor must be managed by properly trained personnel at a tertiary care center in order to avoid the morbidity or mortality.

     

Maternal mortality ratio in selected rural communities in Kebbi State,Northwest Nigeria

Background

Maternal mortality remains a topical issue in Nigeria. Dearth of data on vital events posed a huge challenge to policy formulation and design of interventions to address the scourge. This study estimated the lifetime risk (LTR) of maternal death and maternal mortality ratio (MMR) in rural areas of Kebbi State, northwest Nigeria, using the sisterhood method.

Methods

Using the sisterhood method, data was collected from 2917 women aged 15–49?years from randomly selected rural communities in 6 randomly selected local government area of Kebbi State. Retrospective cohort of their female siblings who had reached the childbearing age of 15?years was constructed. Using the most recent total fertility rate for Kebbi State, the lifetime risk and associated MMR were estimated.

Result

A total of 2917 women reported 8233 female siblings of whom 409 had died and of whom 204 (49.8%) were maternal deaths. This corresponds to an LTR of 6% (referring to 11?years before the study) and an estimated MMR of 890 deaths/100,000 live births (95% CI, 504–1281).

Conclusion

The findings provide baseline information on the MMR in rural areas of the State. It underscores the need to urgently address the bane of high maternity mortality, if Kebbi State and Nigeria in general, will achieve the health for all by year 2030 as stated in the Sustainable Development Goals (SDGs).

     

A Review of Outcomes in Pregnant Women with Portal Hypertension

Background

The course of pregnancy in a woman with portal hypertension is a difficult one as it is associated with complications like variceal bleeding, splenic artery rupture and coagulopathy. All these pose a threat to a woman’s life. Although this condition is rare, every obstetrician should have a high index of suspicion when an antenatal mother presents with splenomegaly, thrombocytopenia or hematemesis. Hence, we aimed to review maternal and fetal outcomes in pregnant women with portal hypertension.

Methods

In a retrospective observational study, 41 women and 47 pregnancies were evaluated, from January 2000–December 2015 at Fernandez Hospital, a tertiary referral perinatal center. Maternal outcomes studied were variceal bleed during pregnancy, surgical procedures, morbidity and mortality. Neonatal variables were gestational age at delivery, birth weight and morbidities.

Results

Mean maternal age was 26.4 years. Average gestational age at delivery was 36.5 weeks. Mean birth weight was 2507.5 g. There were three maternal deaths out of 47 deliveries, the cause of death was massive variceal bleed in one, the second one was due to cardiac arrest on MRI table, and the third death was due to splenic hilar vessel bleed. There was one stillbirth, and no neonatal deaths.

Conclusion

A multidisciplinary approach is essential to improve perinatal outcomes in pregnancy complicated by portal hypertension. Surgical measures to reduce portal venous pressure done before pregnancy or beta blockers during pregnancy might help reduce sudden variceal bleeds.

     

Clinical characteristics of acute pancreatitis in pregnancy: experience based on 121 cases

Purpose

Acute pancreatitis in pregnancy (APIP) is a rare condition; however, it markedly affects maternal and fetal health. This study aimed to describe the types, clinical characteristics, mortality, and the safety and necessity of gestation termination of acute pancreatitis in pregnancy (APIP).

Methods

We retrospectively reviewed 121 APIP cases in the Gastroenterology Department of The First Affiliated Hospital of Nanchang University. APIP diagnosis were based on 2012 Atlanta Criteria. The correlation between APIP types, severity, biochemical parameters and mortality was analyzed.

Results

The most common symptoms for APIP were abdominal pain (86.8%) and vomiting (73.6%). The most common causes for APIP were gallstone (36.4%) and hypertriglyceridemia (32.2%) and hypertriglyceridemic APIP was correlated with a higher rate for local complication (P = 0.012). Serum calcium level was negatively correlated with the severity of APIP (P < 0.01). The overall maternal and fetal mortality rate were 3.3% (4/121) and 11.6% (14/121), respectively. The severity of APIP was significantly correlated with higher risks for maternal and fetal death (P < 0.01). 72.7% of moderate-to-severe APIP patients underwent Cesarean section to terminate gestation safely.

Conclusion

The most common causes of APIP were gallstone and hypertriglyceridemia. Lower level of serum calcium could be used as an indicator for the severity of the APIP. The severity of APIP was associated with higher risk for neonate asphyxia, and maternal and fetal death.

     

Neonatal and maternal risk in Hermansky–Pudlak syndrome: peripartum management—brief report and review of literature

Introduction

Challenges of modern medicine are peripartum bleeding complications as one of the most frequent cases of emergency in obstetrics with a prevalence of 0.5–5.0 %, meaning the main cause of maternal morbidity and mortality. In this context, inherited diseases such as Hermansky–Pudlak syndrome (HPS) should be recognized. HPS is a rare disease and belongs to a heterogeneous group of autosomal recessive disorders characterized by the triad of partial oculocutaneous albinism, disorder of “ceroid” metabolism and platelet storage pool deficiency with bleeding disorder.

Materials and methods

We report on a 30-year-old primipara, to show the peripartum obstetrical and anaesthesiological management. The patient presented with contractions in our outpatient department in the 39th gestational week. In previous operations there were bleeding complications due to HPS.

Discussion

Therefore, to minimize bleeding complications we aimed a vaginal birth, advised against the peridural anesthesia and optimized the coagulation parameters. The subsequent delivery was performed as vacuum extraction without complications. Patient and newborn could be discharged from the hospital without complications.

Conclusion

In conclusion, decisive factor for patients with bleeding disorders is a close interdisciplinary cooperation between obstetrician and anesthesiologist.